Summer 2012, Volume 37, Number 3 - Association of Schools and ...
Summer 2012, Volume 37, Number 3 - Association of Schools and ... Summer 2012, Volume 37, Number 3 - Association of Schools and ...
vices to the people in the community. The patient had received medical care at the clinic during the past 4 years, although this was the first time she was examined at the eye clinic. The patient could not recall the date or provider of her last eye exam. Her main complaint was eye fatigue. Her eyes felt “heavy and tired.” The eye fatigue would occur after the patient had been working all day on the computer, and it had started 3-4 months ago. In the past, the eye fatigue had resolved on its own. The patient did not wear any spectacle correction and reported good distance and near vision. The patient felt the eye fatigue was related to excessive computer use and an increase in job responsibilities, which occurred 3-4 months ago. The patient, an administrative assistant at a local university, reported spending approximately 6-8 hours per workday on the computer. She said the symptoms did improve on the weekend with less computer use, and she did not report any other ocular symptoms. Past ocular history of the patient and her family were unremarkable. Her medical history was positive for hypertension for the past 14 years, obesity, asthma and depression. The patient reported longstanding (ongoing at least 3-5 years), occasional headaches relieved by Motrin. The headaches were not related to her complaint of eye fatigue and occurred randomly. There had been no recent changes in her headaches. Her primary care physician (PCP) had evaluated the headache complaint and felt tension headaches were the most likely cause. The patient’s current medications were: hydrochlorothiazide 25 mg per day, linsinopril 40 mg per day, atenolol 50 mg per day, and Flovent twice daily. The patient was allergic to Augmentin and morphine. The patient reported fair compliance with hypertension medications. She admitted to not using all three of the medications prescribed for hypertension on a consistent basis. The patient’s medical records were accessed by an electronic medical records system and indicated blood pressure readings of 150/103 mmHg in 2011 and 156/103 mmHg in 2010. At her annual physical exam in 2011, the patient’s height was recorded as 61 inches and her weight was recorded as 260 lbs. The patient was alert and oriented and reported no current use of recreational drugs or alcohol. The patient said she smoked half a pack of cigarettes per day. The initial differential diagnosis based on symptoms and case history consisted of: dry eye syndrome (primary or secondary), uncorrected refractive error, specifically hyperopia, binocular/ accommodative anomalies, or asthenopia related to excessive computer use. The patient was also considered at risk for hypertensive retinopathy secondary to her history of poor compliance Distance and near visual acuity, sc Pupils Motility-extra ocular muscles OD and poor control. The findings for the comprehensive eye exam are listed in Table 1. The initial impression was bilateral disc edema. Hypertensive emergency, also known as malignant hypertension, vs. other causes for the disc edema were considered. Moderate hypertensive retinopathy with other causes for the disc edema was also a possibility. Although there are many possible differential diagnoses for disc edema, IIH, space-occupying lesion or infection were the most significant at this time. OS 20/20 20/20 Pupils equal, round and reactive to light (PERRL) Negative afferent pupillary defect (APD) Smooth, accurate, full and extensive Color vision (Ishihara) 11/11 11/11 Cover test Ortho dist and 4 prism diopters exophoria at near Finger counting fields Full Full Near-point convergence To the nose Retinoscopy +0.50= -0.25 x 90 +0.25 Subjective refraction +0.75= -0.25 x 90 20/20 Plano 20/20 Slit lamp Capped meibomian glands lower lid Otherwise all structures unremarkable TBUT 5 seconds 5 seconds Intraocular pressures (GAT) @ 6 p.m. Dilated @7:30 p.m. Patient gave consent for dilation and indicated she understood benefits and potential side effects Fundus exam with 90D lens and binocular indirect ophthalmoscopy Blood pressure with largeperson cuff, patient sitting Table 1 Comprehensive Initial Eye Exam: May 3, 2011 15 mmHg 10 mmHg 1 drop 2.5% phenylephrine (punctal occlusion) 2 drops 1.0 % tropicamide Disc: elevated, blurred margins, 360 degrees, hyperemic in color Blood vessels: A/V crossing changes with engorgement of vessels Background: multiple flame-shaped hemorrhages Cup/disc estimate: H/V 20/20% Macula: clear Periphery: no holes, tears or detachments Right arm 180/115 mmHg Capped meibomian glands lower lid Otherwise all structures unremarkable 1 drop 2.5% phenylephrine (punctal occlusion) 2 drops 1.0 % tropicamide Disc: elevated, blurred margins, 360 degrees, hyperemic in color Blood vessels: A/V crossing changes with engorgement of vessels Background: multiple flame-shaped hemorrhages Cup/disc estimate: H/V 20/20% Macula: clear Periphery: no holes, tears or detachments Left arm 160/120 mmHg Fundus photos Figure 1 OD Figure 2 OS Optometric Education 116 Volume 37, Number 3 / Summer 2012
Additional impressions were meibomian gland dysfunction with secondary dry eye, minimal refractive error OD, and asymmetric intraocular pressure. The plan was to immediately escort the patient to the urgent care clinic, which was located within the health center. The next day, the patient would report to the emergency room (ER) of a local hospital, with a follow-up neuroophthalmology appointment within 1 week. Both the urgent care clinic and ER physicians were called in advance to prepare them for the patient’s visit. Plans for the diagnoses of meibomian gland dysfunction with dry eye, refractive error and asymmetric intraocular pressure were deferred until the more emergent issues were addressed. Patient education The patient was educated on the retinal findings and elevated blood pressure. The potential plan for the patient was discussed with the patient. The patient preferred to visit the urgent care department that night for blood pressure control and the ER the next morning for imaging. The patient was also educated on the importance of compliance with the urgent care and ER visits. The patient was told that the disc edema could be the result of the increase in blood pressure or other conditions. The patient was informed that the other conditions ranged from benign conditions to potentially life- or sightthreatening conditions. The patient was told that the emergency department of the local hospital was the best place to quickly implement the necessary testing to accurately diagnose and manage her condition. The patient was informed of the importance of proper and timely diagnostic testing, which necessitated the visit to the ER. The patient indicated understanding by paraphrasing in her own words the information she received. The patient had many questions and was upset by the potentially serious findings revealed during the examination. She did not anticipate her routine comprehensive exam would necessitate a visit to the ER. As much as possible, all of the patient’s questions were answered and the patient was reassured. The patient was given the clinician’s cell phone number and was told that Figure 1 Right Eye at Comprehensive Initial Exam: May 3, 2011 Figure 2 Left Eye at Comprehensive Initial Exam: May 3, 2011 Optometric Education 117 Volume 37, Number 3 / Summer 2012
- Page 1 and 2: The Journal of the Association of S
- Page 3 and 4: OPTOMETRIC EDUCATION ISSN 1933-8880
- Page 5 and 6: OPHTHALMIC The following companies
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- Page 25 and 26: The model estimates 39,445 clinicia
- Page 27 and 28: when given a choice, patients subco
- Page 29: Idiopathic Intracranial Hypertensio
- Page 33 and 34: • The patient was reminded she co
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- Page 37 and 38: Optic nerve sheath fenestration and
- Page 39 and 40: color vision. 25 Therefore, other c
- Page 41: tions in idiopathic intracranial hy
Additional impressions were meibomian<br />
gl<strong>and</strong> dysfunction with secondary<br />
dry eye, minimal refractive error OD,<br />
<strong>and</strong> asymmetric intraocular pressure.<br />
The plan was to immediately escort the<br />
patient to the urgent care clinic, which<br />
was located within the health center.<br />
The next day, the patient would report<br />
to the emergency room (ER) <strong>of</strong> a local<br />
hospital, with a follow-up neuroophthalmology<br />
appointment within 1<br />
week. Both the urgent care clinic <strong>and</strong><br />
ER physicians were called in advance<br />
to prepare them for the patient’s visit.<br />
Plans for the diagnoses <strong>of</strong> meibomian<br />
gl<strong>and</strong> dysfunction with dry eye, refractive<br />
error <strong>and</strong> asymmetric intraocular<br />
pressure were deferred until the more<br />
emergent issues were addressed.<br />
Patient education<br />
The patient was educated on the retinal<br />
findings <strong>and</strong> elevated blood pressure.<br />
The potential plan for the patient was<br />
discussed with the patient. The patient<br />
preferred to visit the urgent care department<br />
that night for blood pressure control<br />
<strong>and</strong> the ER the next morning for<br />
imaging. The patient was also educated<br />
on the importance <strong>of</strong> compliance with<br />
the urgent care <strong>and</strong> ER visits.<br />
The patient was told that the disc edema<br />
could be the result <strong>of</strong> the increase<br />
in blood pressure or other conditions.<br />
The patient was informed that the<br />
other conditions ranged from benign<br />
conditions to potentially life- or sightthreatening<br />
conditions. The patient<br />
was told that the emergency department<br />
<strong>of</strong> the local hospital was the best<br />
place to quickly implement the necessary<br />
testing to accurately diagnose <strong>and</strong><br />
manage her condition. The patient was<br />
informed <strong>of</strong> the importance <strong>of</strong> proper<br />
<strong>and</strong> timely diagnostic testing, which<br />
necessitated the visit to the ER. The<br />
patient indicated underst<strong>and</strong>ing by<br />
paraphrasing in her own words the information<br />
she received.<br />
The patient had many questions <strong>and</strong><br />
was upset by the potentially serious<br />
findings revealed during the examination.<br />
She did not anticipate her routine<br />
comprehensive exam would necessitate<br />
a visit to the ER. As much as possible,<br />
all <strong>of</strong> the patient’s questions were answered<br />
<strong>and</strong> the patient was reassured.<br />
The patient was given the clinician’s<br />
cell phone number <strong>and</strong> was told that<br />
Figure 1<br />
Right Eye at Comprehensive Initial Exam: May 3, 2011<br />
Figure 2<br />
Left Eye at Comprehensive Initial Exam: May 3, 2011<br />
Optometric Education 117 <strong>Volume</strong> <strong>37</strong>, <strong>Number</strong> 3 / <strong>Summer</strong> <strong>2012</strong>
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